Laws of Pathophysiology of Migraine in the Third Millennium

Abstract

Science is the art of systematic and reproducible measurements, ultimately leading to knowledge supported by a holistic logic. Besides serendipity, there are 6 ways in general to obtain knowledge: authoritarianism; mysticism; rationalism, empiricism; pragmatism; and scepticism. Over the last 100 years, a canonical mythology – cortical spreading depression (CSD) – has prevailed in migraine pathophysiology. Conversely, a well-defined adaptive/protective role has evolved for CSD in locusts, Drosophila, and mammals. Additionally, an elaborate but entirely symptomatic nosologic system has arbitrarily evolved in migraine / primary headache. While the so-called systematic but symptomatic classification system of migraine / primary headache keeps on advancing the data-bank exponentially, the cause-effect nexus continues to obscure the most important systematic and insightful components of the knowledge of primary headache. The first step in advancing the cause-effect mystery of migraine / primary headache is to create a conceptual, consistent, and important adaptive-pathogenetic divide in the massive and disparate data-linked pathophysiology of the disorder. Once certain definitive principles (not laboratory/neuroimaging / genetic/epidemiologic data) emerge in the science of migraine / primary headache, we become empowered to understand the complex but key phenotypic blueprint as well as the neuro-pathophysiology / neuropsychiatry of the entity, including the visual (nasal visual-field sparing digitally-displaceable and eyeball-movement-synchronous scintillating scotomata), the lateralizing fronto-temporal-nuchal headache exclusively involving the ophthalmic division of the trigeminal nerve, and the associated features such as ‘stress’, ‘post-stress’, ‘autonomic storm’, ‘protean’ and ‘spontaneous’ onset and offset, and headache-aborting nausea-vomiting. In this manner, we have also evolved principles to begin to understand the most complex female predominance of migraine patients in adults [F:M=3:1] as well as the decline of prevalence in migraine attacks following menopause and advancing age. The Laws of the Pathophysiology of Migraine encompass the invaluable neurological / neuro-ophthalmological shift in pathophysiology from the brain to the eye.